Are you indulging in medical shopping?

The line that divides “second opinion” from “medical shopping” is a blurred one.

“Second opinion” is the seeking of another medical opinion to verify or validate what the first doctor had diagnosed or advised, and is often quite a valuable step. Most in their normal senses would not seek another opinion for a common cold. On the contrary if the diagnosis is of a sinsister kind such as cancer, or if the  treatment advised is of the risky or expensive kind, such as a heart surgery, it is quite natural for a patient  to seek a confirmation or endorsement by another expert in the field. Indeed, good physicians and surgeons often advise their patients to consult a second physician so as to get convinced of the unpleasant diagnosis and then return with greater motivation to embark on a treatment that is challenging.

The diagnosis of cancer is certainly one such situation. It often comes as a shock and evokes a sense disbelief and denial in patients with thoughts like “it just can’t be true, I just had symptoms of indigestion” or “it cannot be happening to me”. A second evaluation by a competent doctor re-confiring the diagnosis helps the patient to accept the unpleasant truth.

A similar situation often occurs with patients undergoing coronary angiography for evaluation of heart symptoms. Detection of narrowing of arteries comes as unpleasant news, but if all 3 arteries are found to be thinned out and the cardiologist advises coronary bypass surgery rather than angioplasty, the patient usually gropes for a second opinion before subjecting himself to the operation.

Medical shopping on the other hand is quite akin to what we do while buying vegetables, going from one grocer to another enquiring the rates of cauliflowers, seeing their size,  and at times bargaining, before making our purchase. There are people who in their contrived habit of seeking the cheapest will enquire about the cost of endoscopy in 5 centres before going in for one. It may not always be the price, but the popularity of the doctor or the market-stature of the clinic instead.

Once a “noveau riche” businessman’s wife in her 40s, brought her 12 year old daughter, who had been complaining of abdominal pain for a month, to me. The child seemed to be in no distress as she sat smilingly across the table. As I went through her history and scanned the results of the innumerable ultrasound and CT scan tests she had gone through, the mother proudly told me that she had consulted 18 of the top pediatricians, surgeons and gastroenterologists of the city before coming to me.

I discovered in the course of history-taking that the pain came in the mornings before school, and once allowed her to stay back home, it subsided, permiting her to accompany her mother later to the shopping mall. I could see the disappointment in her face as she left in a huff with her daughter to seek their 20^th medical opinion.

As published in HT City (Hindustan Times) dated 29 January, 2012.

Mind your lingo

Doctors excel at making simple things sound complex and grave by their deft use of terms that sound truely Greek or Latin to our common ears. If, for instance, you go to a doctor with bleeding from the nose, he will diagnose it as “epistaxis”, a word that sounds so ‘propah’, but merely means bleeding from the nose!

Many of the diagnostic terms we hear are therefore words from another language that sounds bombastic but tells what the patient told. if you are running fever, your doctor will label it “pyrexia”, and if it has been going on for more than a couple of weeks, he will call it “pyrexia of unknown origin” or PUO to impress you.

The term “heme” stands for blood (remember hemoglobin that gives blood its red colour) and comes in medical jargon in many avatars. If someone vomits blood, the doctor calls it “hematemesis”, if your piles bleed, he says “hematochezia”, and if your urine contains blood, he will label it as “hematuria” and so on..... Great medical terms but meaning only what the patient described in his own simple way!

Doctors are probably encouraged to use this shroud paradoxiacally, by their patients. When I write “giddiness” in the case file, my patients give me that disappointed “ye to mujhe bhi pata tha” look, but when I write “vertigo”, they feel reassured that this guy knows his stuff!. “Double vision” is therefore “dyplopia”, “night blindness” is “nyctalopia”, skin rash is “exanthema” and running nose “corrhyza”.

Once you know that the Latin word for pain is “algia”, you can tag it to any portion of the body that pains and create your own diagnosis. Painful joints become “arthralgia”, pain in muscles “myalgia”, pain in nerves “neuralgia” and pain in the anus “proctalgia”!

Similarly, increased size of a portion of the body is described by tagging “megaly” to it. If someone therefore has an enlarged liver, it is termed “hepatomegaly”, if the spleen is enlarged, “splenomegaly”, if the heart grows big, it is called “cardiomegaly”, and for a swollen head doctors couch it as “craniomegaly”.

While these terms are of little value in most instances, there are situations where they help. Patients are often traumatized when the word “cancer” appears in medical discussions on their bedside. Discrete doctors therefore use terms such as “malignancy” (most people have become familiar with this word nowadays!) or “mitosis” to hide the meaning from patients, till the stage comes for divulging.

Another comical word that sounds medically bombastic and finds a place in several dignostic terms is “idiopathic”, which really means “it is not known”. Doctors once again demonstrate the unique trait of converting their ignorance into a style-statement by brandishing “idiopathic” for several conditions from a fall in platelet count to increased blood pressure, making a witty teacher remark “Idiopathic is idiotic for the doctor and pathetic for the patient.”

Let us not fool or be fooled by medical jargon!

As published in HT City (Hindustan Times) dated 22 January, 2012.

POP THE PPP PILL

It does not require genius to recognize that the state of health services in Uttar Pradesh is in bad shape, that there is urgent need to explore ways and means to frog-leap in this field. Aptly described being “caught in the gap between our dreams of greatness and the awful reality of our broken health system”, public-private-partnership (PPP or P3) holds promise to kickstart the process of recovery in our resource restricted state.

Where are we at present?

Despite our achievements on the economic and manufacturing fronts, India is lagging considerably behind in its health care, ranking 119 among 169 countries in the World Development Index, and Uttar Pradesh, with its highest density of population, is being ranked  4^th from the bottom among the 15 major states.

The health indices of Uttar Pradesh are well below the country’s average. Our Infant mortality rate (number of babies dying of every 1000 born, a sensitve indicator of the health services) for instance is 85, while Kerala’s is 17 and the country’s average is 58. Or if we look at childhood immunization, only 23 of every 100 1-year olds in the state received all the recommended doses compared with 90% in Kerala and a country average of 48.

How to catch up?

While the country’s healthcare needs much catching up, UP needs to act with even greater urgency if it wishes to erase its dubious distiction of being a lagard. Health-care needs prioritization and needs adoption of an apt slogan for holistic development “roti, kapda, makan, swasth and shiksha”, rather than short-sightedly clamouring for just the 1^st three.

The 3 pillars of healthcare that need bolstering are: money, infrastructure and manpower. The 3 props that can keep the pillars steady are sensible planning, effective execution and vigilant monitoring, things that don’t always come in abundant supply in a state government’s health machinery.

There is no disputing that our health-care sector needs considerable infusion of funds. The government’s present spending on health is 0.9% of the GDP compared with 9% in UK and 16% in the USA. Even if a 3-fold increase occurs as planners are promising, to 4% of GDP, a large gap will still remain between the country’s health needs and funds, as both medical technology and people’s expectations will continue to soar with time.

Public-Private-Partnership (PPP) is a model in which a government service is funded and operated by private players in partnership with the government, and seems particularly promising when a large gap exists between a state’s resources and its needs.

PPP in the health sector has success stories to tell. The best known example is that of the Human Genome Project, a mammoth research venture under the leadership of the National Institute of Health (government agency of the USA) that was initiated to unravel the human genetic code in a span of 10 years. A very successful partnership with a private organization, Celera Corporation, led to infusion of expertice and innovation, and the project finishing 2 years ahead of time and as a thumping success.

An example closer home was installation of an expensive MRI scanner at the Sanjay Gandhi PG Institute in several years ago during a cash-starved phase of the institute’s history. This machine provided much needed service that a tertiary care hospital needed to provide to its patients, and with its maintainance in the private company’s hands, had a strikingly low down-time. The money that gathered from the investigation charges was shared by the institute and the leasing company in a pre-determined ratio and to the satisfaction of both.

What are the types of PPP? There are broadly 2 types of private players: the philanthropic or non-profit ones who do not seek monetary profits, and the commercial ones who invest money in the PPP model with profit as the motive.

Several non-profit organizations operate globally or nationally and can be tapped in the state to improve our health services. The lsit is long and includes examples like the PATH Malaria Vaccine Initiative (MVI), Drugs for Neglected Diseases Initiave (DNDI), Global Alliances for Vaccines and Immunization (GAVI), World Health Organization (WHO), UNICEF, Bill and Melinda Gates Foundation, Bristol Myers Squibb Foundation, Coalition for Eradication of Viral Hepatitis in Asia Pacific (CEVHAP) and HOPE Initiative.  For the government to engage actively with these organizations, invite them to operate and deliver in this region, and get into partnership with them makes good sense. As they do not run for profit, and have global accountability standards, they make safe partners and bring in modern expertice apart from the much needed resources.

PPP with the corporate sector is however a different ball game, and needs to be evaluated with caution as the private partner’s driving motive in investing money is financial profit, and the money needs to be genearted from the users, who are residents of the state, and often usually poor.

Some dependence of PPP is however inevitable as the there is not a country in the world where healthcare is financed entirely by the government, and, while health is widely recognized a s a responsibility of the governement, private capital and expertice are increasingly being welcomed to bring in efficiency and innovation. India’s health care industry is a mamoth $ 17 billion, and is growing at 13% annually. Like it or not, the private sector, though largely unregulated and disorganized, , is already providing 80% of our health care services.

PPP ventures have seen, in different states of India, creation of hospitals, running of some aspects of health services, installing and running of equipment, running ambulance services, training manpower and many others. And few of them, to be fair, have done well.

Many have however run into disrepute or loss, reasons for which, analysis shows, are major flaws in the props of planning, execution and monitoring. The implications of PPP in Health-care are somewhat different from that of building roads and bridges. While recovery of money is directly from the end-users in those who use the latter facilities, it is only on the advice of doctors that people use the former; leaving decisions entirely to their discretion without a close watch may pose danger to the vulnerable public.An Ultrasopund machine installed and run by a corporate PPP model, for instance, had many more tests done than were genuinely required, suggesting the possibility of inducement-generated referrals. This assumes significance in India as more than 75% of the expenses are out-of-pocket of citizen with limited means.
Conclusion

Health care needs urgent prioritization in the state, and PPP holds tremendous promise in helping the state fortify the much needed 3 fractured pillars of its healthcare. Attracting the non-profit organizations should be a priority. Considerable proficiency and wisdomare however requiredin planning, executing and monitoring partnership with the corporate sector, in drawing investments in the state, but also ensuring that the services run smoothly and deliver results that benefit the state’s people.

As published in Hindustan Times dated 8 January, 2012.

Much can happen with coffee!

The buck-you-up cup that gets us going in the morning has indeed survived intense scientific scrutiny for 20 years regarding its health safety, and has emerged largely unscathed with, in fact, some benefits to claim instead. A recent study showed that moderate coffee drinkers were less likely to develop liver cirrhosis, degenarative brain disorders, and heart disease.

Scientists, still groping for a cause of the enigmatic Alzheimer’s disease, a degenrative condition of the brain that wipes off its victim’s memory and higher mental functions, were surprised to find that those who drank 3-5 cups of the brew a day had a lower chance of having the disease. A similar “protection” was also seen from another degerative condition of the nerves and brain, called Parkinson ’s disease.

Coffee, a drink made from brewing beans of the coffeacute plant, contains several chemical compounds that affect the human system. Apart from caffeine, the main constituent that provides its stimulant effect, it contains a wide range of other substances, anti-oxidants and minerals such as zinc, selenium and copper.

Coffee is widely believed to have originated in the Arabian Peninsula where its use can be traced to as early as the 15^th century. It was introduced many years later into Europe, the Americas and the rest of the wold. It came to India around the 17^th century when 6 coffee pods were planted near Mysore. The ensuing cultivation and consumption of coffee in the region saw the ushering in of the “kapi” culture that is so prevalent in the south.

The short term effects of the drink are well known; it “stimulates” the brain, helps fight sleep and increases urination. Over-stimalution may cause anxiety, sleeplessness, palpitations, rise in blood pressure and increased blood sugar levels through the release of stress hormones, epinephrine and cortisol. The risk of stillbirths may be increased with excess use during pregnancy, and anemia may occur due to coffee interfering with absorption of iron in the gut.

Population studies however show a lower frequency of a variety of diseases among regular moderate coffee drinkers.They are less likely to develop gallstones, dental caries, gout and show lower rsik of heart disease, hypertension, migraine and diabetes.  Anti-oxidants in the drink probably account for most of these benefits, as do the minerals selenium and zinc, in protecting against diabetes by stimulating the pancreas.

Coffee drinking is churning society too, widening the rift between the “classic” filter-coffee lover, and the new- age young aficionado who can confidently have his pick from the mind-boggling variety that a coffee-bar menu now offers: cappucino, latte or expresso, Arabic, Brazilian or Indian, large, moderate or small, decaf or normal, hot or iced, with or without sugar etc, his nonchalance often assuming a style statement.

Coffee drinking is clearly evolving, offering a type of drink, a place and a style for everyone and every occasion.  How did you have your morning cup?

As published in HT City (Hindustan Times) dated 15 January, 2012.

Lessons for Life

Several simple and touching stories, which talk about life and death, have become bestsellers in recent years. Not only  do they give a deep insight into what the process of dying does to our physical self but also about the lessons we learn as we come closer to death.

One such best seller is  “Tuesdays with Morrie” by Mitch Album (Time Warner Books), which is a magical chronicle of a rekindled relationship between a professor, recently detected to have a progressive neurological disease called Amyotrophic Lateral Sclerosis (ALS), and a student he had taught 20 years ago. It was on Tuesdays that the young “student” came in to spend time with Professor Morrie Schwartz, and the story of his last days unfolds over 14 consecutive Tuesdays that he spends with his teacher who battles this relentless disease,

Mitch gets a second and, this time a more practical lesson in life from his ailing professor, and learns to understand the value of relationships with loved ones, and the importance of sharing time with those that ultimately matter, distant from the maze of day-to-day commitments. It also helps Mitch learn how disease and death are ultimately humbling, and how we need to ask bigger questions and cherish the love we get and the time we are granted to bask in its warmth.

This 200 page “cant-put-down” candid tale touches the heart and poses the question “ What would you say to a person or do to him if this were your last meeting?” a disturbing but real question that we make a habit to avoid.

Another true-story international bestseller book worth reading is “The Last Lecture” (Hodder and Stroughton Ltd) by Randy Pausch, a youthful, energetic and cheerful Computer Science Professor at Carnegie Melon, who is diagnosed with advanced pancreatic cancer at a young and productive phase of his life, with doctors giving him a few months.  Life again poses the same question, “If you only had a short time to live, what would you do?”. And add to that his concern that his children would be too small at the time of his death to have really known their father.

Dr Pausch decides to prepare and deliver the last lecture at his university that will make people remember him for what he was; not just his work, his struggle, his achievements, but more importantly, his emotions and his sportsman-spirit with which he accepts his inevitable fate. Entitled “Really Achieving Your Childhood Dreams”, it makes us pause and notice that what we spend most time being dragged into doing might not be what we had set out to achieve in our dreams. “We cannot change the cards we are dealt, just how we play the hand”, says Dr Pausch.

Books have a quiet way of communicating life’s important lessons, far from the glare and din of movie theatres and TV boxes. They, in addition, give you that precious time and space to ponder and reflect. Try these books.

As published in HT City (Hindustan Times) dated 8 January, 2012.

Looking ahead

For those of you who have recovered from the New Year’s Eve bash and picked up the HT City this sunny morning to read the Health Adda, I can offer to take you through a “health bulletin” ride of 2011, and share what we have learnt.

The year had started with expectations but ended with a whimper. The sensex had promised to scale new heights but tumbled down to deep lows. The promise of corruption fading from society receded as our ministers took to mock fights in parliament.

The last year saw the departure of several celebrities. Many, who died in their late 70s or above, went gracefully, leaving pleasant memories and contributions behind. Dev Anand, MF Hussain, Mario Miranda, Bhimsen Joshi, Shammi Kapoor and Elizabeth Taylor belong to this category.

Non-communicable diseases of the heart, brain and kidneys dominated the scene in South Asia. The nawab of Patuadi died due to lung fibrosis. Bhupen Hazarika’s death, though at a ripe 85, was preceded by a prologed kidney ailment. Jagjit Singh’s end was as sad as his songs; a stroke (bleeding in the brain) to high uncontrolled blood pressure pushed him into coma for a few days from which he did not return. His son’s death few years ago from a car accident caused by alcohol, must have contributed to this sensitive singer’s gloom and BP.

Natural disasters caused by global warming continued to play havoc across the globe.  Thousands died in Phillipines from floods, inTurkey from earthquake and in Japan from Tsunami. Further many are probably doomed by exposure to radiation from the Fukushima nuclear reactor that leaked after the tall waves struck it.

Cancer grabbed the limelight in the Americas. While an Indian born American doctor’s book “The Emperor of all Maladies” won the Pulitzer, heads of four Latin American countries got diagnosed with cancer, prompting the Venezuelan president Hugo Chavez to suspect an American hand in causing them.

Violence featured as a major killer in the middle east, Africa, Afghanistan and Pakistan. Two prominent leaders, Muammar Ghadafi and Osama Bin Laden exemplified the adage “those who live by the sword, die by the sword”.

Apple’s Steve Job’s death drew the world’s attention to a rather rare form of pancreatic cancer called NET (neuro-endocrine tumor) that hehad battled for several years, including a liver transplantation.

Few young deaths shook us. The famous singer, Amy Winehouse’s death from drug overdose reminds us of the growing levels of frustration and directionless lives of our youngsters, and the growing epidemic of drug culture. And Ayan’s (Md Ajzharuddin’s son) death from a motorbike crash confirmed WHO predictions that traffic accidents will become a major killer in the coming years.

A tense story with a lesson was that of Shashi, a young nurse in our endoscopy department who was knocked down from her 2-wheeler when she was on her way home from hospital on 19^th September. The impact broke the helmet she was wearing, but she escaped a major head injury and death, and is back with a smile at her work place.

I hope 2012 brings good health to all of you. 

As published in HT City (Hindustan Times) dated 1 January, 2012.